Barriers to Healthy Eating Among High School Youth in Rural Southern Appalachia

Introduction Diet and nutrition play an important role in a child’s health and reduce the risk of numerous health problems including obesity. Dietary habits can be difficult to modify in children, particularly in Appalachia, where access to affordable, healthy foods is limited. Purpose To examine barriers to healthy eating among Appalachian youth. Methods In 2013–2014, data were gathered via focus groups and interviews from parents, school personnel, and adolescents (N=99) in six counties across southern Appalachia. Data were analyzed using thematic network analysis. Analysis was completed in 2015. Results Participants identified multiple barriers to healthy eating among adolescents. Barriers comprised three global themes: cultural norms, school-based nutrition policy and programming, and rurality. Within the individual and home environment, beliefs and practices, time management, and preference for unhealthy foods affected adolescents’ dietary behaviors. Schools faced challenges in terms of translating nutrition policy into practice, providing nutrition education, and engaging stakeholders. Limited socioeconomics and food deserts/swamps were community-level impacts. Implications Participants discussed how adolescents’ eating behaviors were shaped by social, physical, and environmental factors (e.g., cultural norms, school-based nutrition policy/programming, and rurality). These findings provide important insights into barriers to healthy eating in this population and point to future directions for research and practice. For example, the findings can be used by school personnel to develop ecologic approaches to school-based nutrition programming in Appalachia. Student associations can also use these findings to actively participate in efforts to improve school food offerings.

whereas a poor diet can increase risk of health problems like obesity. 3 Among adolescents, diets are largely composed of empty-calorie foods and few fruits and vegetables. Dietary habits can be difficult to modify in adolescents, particularly in Appalachia, where access to affordable, healthy food is limited. 4 Research examining the underlying contextual factors that contribute to adolescents' dietary behaviors in Appalachia can be used to inform the development of effective obesity-prevention programming. 5 Few studies have used qualitative methods to examine these factors among adolescents in Appalachia. 5,6 This study seeks to address this gap by examining barriers to healthy eating in this population.

METHODS
During 2013-2014, thirteen focus groups (range, 3-7 participants) and 22 semistructured interviews were conducted to explore strategies to engage parents in adolescent obesity prevention. The current study focuses on a subset of questions related to barriers of healthy eating (Table 1). Purposive sampling methods were used to recruit participants. Recruitment efforts included flyers and e-invites using school email distribution lists. Participants included parents of adolescents (n=39) and teachers (n=38) from five high schools in the control arm of the Team Up for Healthy Living project (NIMHD Grant R01MD006200).
High school students (n=21) were recruited from two high schools in a separate contiguous county to avoid biasing the Team Up project ( Figure 1; Table 2).
Written consents and child assents were obtained prior to beginning the study.
College students were trained to conduct interviews. Sessions lasted 30-45 O minutes and were audiotaped and transcribed verbatim. Analysis was completed in 2015. What role should parents and families play in encouraging healthy habits among high schoolers?
How can we encourage high schools to be more involved in promoting healthy habits among high schoolers?
How can we encourage parents and families to be more involved in promoting healthy habits among high schoolers?
Discuss some ways we could involve parents in programs to encourage healthy eating and physical activity in their children.
Thematic network analysis (TNA) was used to analyze the text. 7 TNA uses a multi-stage process which includes: (1) identification of basic themes originating from the coded material, (2) rearranging basic themes into organizing themes,

Analysis of participants' responses resulted in identification of eight central
organizing themes and three global themes: cultural norms, school-based nutrition policy/programming, and rurality ( Table 3). The term participant is used to denote the shared opinions of parents, teachers, and students. Other implementation challenges focused primarily on foods served at lunch.
Teachers and parents expressed concern about portion sizes and students commented on food quality. Students described foods as greasy and felt they had limited access to fresh foods. As a result, most students in the study did not eat school lunch. They either ate from vending machines or after school. probably can't afford all the healthy stuff that we're requesting.
Food deserts/swamps. Participants voiced concerns about the lack of grocery stores and high prevalence of fast-food stores in their communities. Distance to grocery stores created a reliance on convenience stores even though foods were more expensive. Many parents expressed a desire to eat healthier and some were employing better food purchasing habits. However, most parents said their children had access to unhealthy foods at home.
Participants felt that easy access to fast-food stores made them difficult to avoid.
Students were observed eating fast food before and after school, noting the long lines at the drive thru. It was not uncommon for students to eat out every day.

STRENGTHS AND LIMITATIONS
The study has several strengths including a large sample size and insights from multiple groups (e.g., parents, teachers, students). Study limitations include the possibility of self-selection bias; however, use of multiple data sources minimized this bias. Qualitative research is subjective in nature. Thus, the analyst can influence the development of themes. To enhance analytic rigor, multiple coders analyzed the data independently and met regularly to confirm findings.

IMPLICATIONS
This study provides important insights into barriers to healthy eating among adolescents in southern Appalachia and points to future directions for research and practice. Participants discussed how adolescents' eating behaviors were shaped by social, physical, and environmental factors (e.g., cultural norms, school-based nutrition policy/programming, and rurality). Much of the discussion centered around two environmental factors associated with rurality (e.g., limited socioeconomics and food deserts/swamps). While these factors are often more resistant to change, participants identified several windows of opportunity that school administrators and local officials can consider when developing local health policies. These included expanding stakeholder engagement, supporting local schools, and making healthy eating more affordable. While similar findings have been reported elsewhere, 5,6,8 this study is unique because it is one of only a few studies 5,6 to employ qualitative methods to assess barriers to healthy eating among adolescents in Appalachia.
Residents in Appalachia are less likely to meet dietary guidelines and may experience higher levels of food insecurity compared with residents nationally. 9 Poor eating habits and disparities in obesity rates have also been observed among southern Appalachian youth when compared nationally. 2,10 Appalachian youth may experience greater difficulty changing eating habits than non-Appalachians, 11 due to cultural, economic and geographic barriers. 12 The findings from the current study can be used by school health personnel to develop ecologic approaches 5,12 to school-based health promotion programming in the region. Student associations can also use these findings to actively participate in efforts to improve school food offerings.

SUMMARY BOX
What is already known about this topic? Dietary habits can be difficult to modify in adolescents, particularly in Appalachia, where access to affordable healthy foods is limited. What is added by this report? This study describes the complex and challenging role that individual, home, school, and community environments have on healthy eating among adolescents and how these findings can be used by school health personnel to develop ecologic approaches to school-based health promotion programming in the region. What are the implications for public health practice, policy, and research? These findings provide important insights into barriers to healthy eating in this population and point to future directions for research and practice. For example, the findings can be used by school personnel to develop ecologic approaches to school-based nutrition programming in Appalachia. Student associations can also use these findings to actively participate in efforts to improve school food offerings.